IRDAI Sets 3-Hour Time Limit For Cashless Claims Approval In Health Insurance

The Insurance Regulatory and Development Authority of India (IRDAI) has introduced significant changes to the regulatory norms governing health insurance policies. Issuing a comprehensive Master Circular on Health Insurance Products, the IRDAI has repealed 55 previous circulars.

Under the new guidelines, the IRDAI mandates that insurers must grant final authorization for cashless claims within three hours of receiving the discharge request from the hospital. In cases of emergency, insurers are required to decide on cashless authorization requests immediately.

The regulator emphasized that policyholders should not be made to wait for discharge from the hospital. If there is any delay beyond the three-hour limit, any additional charges incurred by the policyholder due to the delay shall be borne by the insurer from shareholder funds.

To facilitate prompt decision-making on cashless authorization requests, insurers are directed to implement necessary procedures by July 31, 2024. Additionally, insurers are encouraged to establish dedicated help desks at hospitals to expedite cashless requests.

Other key changes announced by the IRDAI include:

• Insurers must offer a wider range of products, add-ons, and riders to provide policyholders with more choices.
• Policyholders with multiple health insurance policies will have the option to choose the policy under which they prefer to claim.
• Insurers are required to provide a Customer Information Sheet (CIS) with every policy document.
• Policyholders may receive rewards for no claims during the policy period, such as increased sum insured or discounted premiums.
• In case of policy cancellation during the term, policyholders will receive a refund of the premium for the unexpired policy period.

These changes come in response to difficulties faced by insurance policyholders in processing health insurance claims, as highlighted in a survey by Local Circles. The survey found that 43% of policyholders encountered challenges with their health insurance claims, with delays in claim processing being a significant issue.